Rheumatoid arthritis: treatment and remission

The definition of remission for people with rheumatoid arthritis (RA)—as well as how many people with RA truly reach remission—is heavily debated. Rates of remission for RA have been reported ranging from as low as 5 percent to as high as 50 percent, depending on how RA remission is defined. 

While it's difficult to say exactly how common rheumatoid arthritis remission is, or how long it lasts, there's still good news for RA patients in treatment or just starting treatment. Experts generally agree getting early, aggressive treatment—usually combination drug therapy, using DMARDs and biologic medications for RA—will give you a good chance of remission, and that you should keep remission as your ultimate treatment goal. 

Here are three ways to better understand what RA remission may mean for you: 

• True remission. In true remission, all of your symptoms (swelling, pain, fatigue) are gone, and X-rays show that the disease has been stopped. There is no new joint damage, and old damage appears to be healing. You will still need to take medication—rheumatoid arthritis never goes away completely—but this is the best-case scenario. Early, aggressive treatment is your best shot at true remission. 
• Clinical remission. All of your symptoms are gone, but X-rays still show evidence of disease activity. New joint damage appears to be occurring and old damage is not healing. This is the second-best treatment scenario. 
• Near remission. Near remission is usually the goal for people who've had RA for many years. Near remission means your symptoms have been reduced, and your day-to-day functioning has improved. This scenario requires more day-to-day management of the condition, including self-care. 

Getting started with RA treatment 

Because the overall goal of rheumatoid arthritis treatment is to halt or at least quiet and slow the disease while improving your well-being and relieving pain and other symptoms, your rheumatologist is likely to recommend an aggressive treatment plan from the start. In most cases, this means a combination of powerful medications that not only treat your symptoms, but also slow and prevent joint damage. The newest drugs used to treat RA are commonly called biologics (also known as biologic response modifiers, BRMs or TNF-alpha blockers). Biologics are often combined with DMARDs (disease-modifying antirheumatic drugs) to treat RA. 

Monitoring your RA treatment progress 

Aggressive treatment of RA requires frequent monitoring to check on how well the treatment is working. Your rheumatologist may want to see you as often as once a month, or every 2 to 3 months, depending on the stage of your disease and the medications you're taking. 

Frequent monitoring helps your rheumatologist treat toward a target, in much the same way high blood pressure is treated toward a target. But evaluating progress in RA isn't quite as straight forward as taking a blood pressure reading. To monitor the treatment of RA, your rheumatologist will look at a combination of factors and calculate a "disease activity" score for you. Your score tells how well your treatment is doing at moving you toward remission, and is based on the answers to these four key questions: 

1. How do you feel: better or worse? This is your personal opinion about how you feel. You may be asked to fill out a written questionnaire about how you're feeling. Written answers are less likely than verbal answers to be misinterpreted, can be more easily "scored," and can also be added to your medical records. 
2. Do you look and sound better? This is your rheumatologist’s opinion, based on what they can see at your visit. 
3. What do your blood tests show? Blood tests will be done to look for signs of treatment side effects and to check your erythrocyte sedimentation rate (ESR) and/or your C-reactive protein (CRP) levels to see whether the inflammation in your body is being reduced. 
4. How do your joints look? Your rheumatologist may schedule imaging (X-ray, MRI, CT scan or ultrasound) to see what effect treatment is having on joint damage and erosion: Has it slowed, gotten worse or stopped? This is called "monitoring the radiographic progression" of your RA. Radiographs are X-rays, and monitoring radiographic progression means checking your joint damage with X-rays. This may be done every 6 to 12 months during the first few years of rheumatoid arthritis. 

Is your treatment plan working? 

If your rheumatoid arthritis treatment plan isn't moving you toward remission, your rheumatologist will likely adjust your therapy, which may involve increasing dosages, adding a drug or switching to a different medication. This is called treating toward a target, intensive therapy or aggressive therapy, and it is the most effective way to treat RA. Once you've hit your target (remission), you may be monitored less frequently but will still need to keep an eye on your symptoms and meet regularly with your healthcare team. 

NOTE: Some health insurance companies will cover the most advanced (and expensive) arthritis drugs—the biologic agents—only if your rheumatologist can prove that you have not responded to other medications. Regular score-based monitoring is a good way to provide evidence of your treatment history.